Provider Demographics
NPI:1124084397
Name:PETERSON, JAYNE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1300 N 12TH STREET
Mailing Address - Street 2:SUITE 508
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2849
Mailing Address - Country:US
Mailing Address - Phone:602-839-3927
Mailing Address - Fax:602-839-4233
Practice Address - Street 1:1300 N 12TH STREET
Practice Address - Street 2:SUITE 508
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2849
Practice Address - Country:US
Practice Address - Phone:602-839-3927
Practice Address - Fax:602-839-4233
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ18828OtherSTATE LICENSE
AZ286098Medicaid
Z74588Medicare PIN
AZ18828OtherSTATE LICENSE
C32831Medicare UPIN